Nosocomial infections: A further assault on patients in a high-volume urban trauma centre in South Africa.

BACKGROUND: Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality. Surgical site infection (SSI) rates are reported to range from 2.5% to 41%. HAI increases the risk of death by 2 - 11%, and three-quarters of these deaths are directly attributable to SSIs. OBJECTIVES: To determine the incidence of HAI and to identify risk factors amenable to modification with a resultant reduction in infection rates. METHODS: An analysis of HAIs was performed between January and April 2018 in the trauma centre surgical wards at Groote Schuur Hospital, Cape Town, South Africa. RESULTS: There were 769 admissions during the study period. Twenty-two patients (0.03%) developed an HAI. The majority were men, and the mean age was 32 years (range 18 - 57). The mean length of hospital stay (LoS) was 9 days, higher than the mean LoS for the hospital of 6 days. Fourteen patients underwent emergency surgery, 3 patients underwent abbreviated damage control surgery, and 9 patients were admitted to the critical care unit. Most patients with nosocomial sepsis were treated with appropriate culture-based antibiotics (82%). Four patients were treated with amoxicillin/clavulanic acid presumptively prior to culture and sensitivity results, after which antibiotic therapy was tailored. All but 1 patient received antibiotics. CONCLUSIONS: A combination of measures is required to prevent trauma-related infections. By determining the incidence of nosocomial infections in our trauma patients, uniform policies to reduce infection rates further could be determined. Our low incidence of infection may be explained by established preventive care bundles already in place.

Surgical resources in South Africa: a review of the number of functional operating theatres.

BACKGROUND: Surgery has previously been neglected as a development initiative, despite the obvious effect of surgical illnesses on morbidity and mortality. Recently, greater attention has been given to surgical services, as there is growing evidence of cost-effectiveness of surgical interventions. Operating theatre numbers have been used as a measure of surgical capacity, despite there being limitations associated with this use of this metric. This study aims to analyse part of the surgical resources in South Africa. METHODS: A descriptive analysis of surgical infrastructure in all nine provinces was performed. The total number of functional operating theatres was documented for all public and private hospitals in South Africa. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014. RESULTS: The results showed 3.59 operating theatres per 100 000 population. This fell below the global average of 6.2 operating theatres per 100 000 as well as other developed countries. Theatres were concentrated in metropolitan areas, and there were a greater number of private operating theatres per insured population than in the uninsured public sector. CONCLUSION: Strengthening surgical systems will reduce the surgical burden of disease and improve health outcomes globally. Little is known about the available surgical resources such as operating theatre density, although using this metric to evaluate surgical capacity has its limitations.

Surgical resources in South Africa: an analysis of the inequalities between the public and private sector.

BACKGROUND: The full extent of the global burden of surgical disease is largely unknown, however, the scope of the problem is thought to be large. Despite the substantial burden of surgical disease, surgical services are inaccessible to many of those who need them most. There are disparities between public and private sectors in South Africa, which compound inequitable access to surgical care. This study forms part of a series analysing surgical resources in South Africa. METHOD: This study involved a descriptive analysis of surgical resources and included the total number of hospitals, of hospital beds, the number of surgical beds, the number of general surgeons (specialist and non-specialist), and the number of functional operating theatres in South Africa. A comparison was performed between the public and private sectors. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014. RESULTS: Surgical resources were concentrated in metropolitan areas of urban provinces. There were striking differences between the public and private sectors, where private resources were comparable to those available in high income countries (HICs). CONCLUSION: Improving access to surgical services in lower middle income countries (LMICs) requires addressing gaps between the public and private sector regarding infrastructure, personnel, as well as equipment. These data identified disparities between geographic regions which may be contributing to ongoing inequity in South Africa, and by doing so allows for evidence-based planning towards improving surgical infrastructure and workforce.

Orthopaedic Surgeon Density in South Africa.

BACKGROUND: In the era of global surgery, there are limited data regarding the available surgical workforce in South Africa. METHODS: This aim of this study was to determine the orthopaedic surgeon density in South Africa. This involved a quantitative descriptive analysis of all registered specialist orthopaedic surgeons in South Africa, using data collected from various professional societal national databases. RESULTS: The results showed 1.63 orthopaedic surgeons per 100,000 population. The vast majority were male (95%) with under two-thirds (65%) being under the age of 55 years. The majority of the orthopaedic surgeons were found in Gauteng, followed by the Western Cape and Kwa-Zulu Natal. The majority of specialists reportedly worked either full time or part time in the private sector (95%), and the orthopaedic surgeon density per uninsured population (0.36) was far below that of the private sector (8.3). CONCLUSION: Interprovincial differences as well as intersectoral differences were marked indicating geographic and socio-economic maldistribution of orthopaedic surgeons. This parallels previous studies which looked at other surgical sub-disciplines in South Africa. Addressing this maldistribution requires concerted efforts to expand public sector specialist posts as well as quantifying the burden of orthopaedic disease in both private and public sectors before recommendations can be made regarding workforce allocation in the future. LEVEL OF EVIDENCE: IV.

Where are general surgeons located in South Africa?

BACKGROUND: Human resources are the backbone of health-care delivery systems and the lack of surgical workforce in developing countries is often the greatest challenge to providing surgical care. The workforce availability and composition is an important indicator of the strength of the health system. This study aimed to analyse the distribution of general surgeons within South Africa. METHOD: A descriptive analysis of the general surgical workforce in South Africa was performed. The total number of specialist and non-specialist general surgeons working in the public sector in South Africa was documented between the periods from the 1 October 2014 until 31 December 2014. RESULTS: There were significant disparities in the number and distribution of general surgeons in South Africa. There were 1.78 specialist general surgeons per 100 000, of which 0.69 per 100 000 specialist general surgeons were working in the public sector. There were 2.90 non-specialist general surgeons per 100 000. There were 6 specialist general surgeons per 100 000 insured population working in the private sector, which is comparable with the United States (US). Urban provinces such as Gauteng, the Western Cape and KwaZulu-Natal had the largest number of specialist general surgeons per 100 000. These areas had the largest number of medical aid beneficiaries and nearly 60% of specialist general surgeons were estimated to work exclusively in the private sector. CONCLUSION: There was a major shortage of surgical providers in South Africa, and in particular the public sector.

Surgical Resources in South Africa: An International Comparison and Deficit Calculation.

BACKGROUND: Surgical conditions lead to premature death and disability resulting in a massive economic burden. Contributing to this global crisis is the lack of data on the limited surgical infrastructure and workforce in many low- and middle-income countries. METHODS: This study involved a descriptive analysis of surgical resources in South Africa and included the total number of hospitals, number of hospital beds, number of surgical beds, number of general surgeons, and the number of functional operating theatres. All hospitals in South Africa were contacted between the 1 October 2014 and the 31 December 2014. An international comparison of South Africa's surgical resources was then made with several countries. RESULTS: The results showed one hospital per 100,000 population. There were 186.64 hospital beds, 41.55 surgical beds, 1.78 specialist general surgeons, 2.90 non-specialist general surgeons, and 3.59 operating theatres per 100,000 people in South Africa. These numbers fell far below international recommendations, as well as for developed countries such as the UK and USA. CONCLUSION: Strengthening surgical systems will reduce the surgical burden of disease and improve health outcomes globally. This description of surgical infrastructure and workforce provided insight into the surgical capacity of South Africa. Furthermore, this research provided a comparison of surgical resources between South Africa and the rest of the world.

Where are general surgeons located in South Africa?

Background:Human resources are the backbone of health-care delivery systems and the lack of surgical workforce in developing countries is often the greatest challenge to providing surgical care. The workforce availability and composition is an important indicator of the strength of the health system. This study aimed to analyse the distribution of general surgeons within South Africa. Methods: A descriptive analysis of the general surgical workforce in South Africa was performed. The total number of specialist and non-specialist general surgeons working in the public sector in South Africa was documented between the periods from the 1 October 2014 until 31 December 2014. Results: There were significant disparities in the number and distribution of general surgeons in South Africa. There were 1.78 specialist general surgeons per 100 000, of which 0.69 per 100 000 specialist general surgeons were working in the public sector. There were 2.90 non-specialist general surgeons per 100 000. There were 6 specialist general surgeons per 100 000 insured population working in the private sector, which is comparable with the United States (US). Urban provinces such as Gauteng, the Western Cape and KwaZulu-Natal had the largest number of specialist general surgeons per 100 000. These areas had the largest number of medical aid beneficiaries and nearly 60% of specialist general surgeons were estimated to work exclusively in the private sector. Conclusion: There was a major shortage of surgical providers in South Africa, and in particular the public sector

Surgical resources in South Africa: an analysis of the inequalities between the public and private sector

Background:The full extent of the global burden of surgical disease is largely unknown, however, the scope of the problem is thought to be large. Despite the substantial burden of surgical disease, surgical services are inaccessible to many of those who need them most. There are disparities between public and private sectors in South Africa, which compound inequitable access to surgical care. This study forms part of a series analysing surgical resources in South Africa. Methods:This study involved a descriptive analysis of surgical resources and included the total number of hospitals, of hospital beds, the number of surgical beds, the number of general surgeons (specialist and non-specialist), and the number of functional operating theatres in South Africa. A comparison was performed between the public and private sectors. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014.Results: Surgical resources were concentrated in metropolitan areas of urban provinces. There were striking differences between the public and private sectors, where private resources were comparable to those available in high income countries (HICs).Conclusion: Improving access to surgical services in lower middle income countries (LMICs) requires addressing gaps between the public and private sector regarding infrastructure, personnel, as well as equipment. These data identified disparities between geographic regions which may be contributing to ongoing inequity in South Africa, and by doing so allows for evidence-based planning towards improving surgical infrastructure and workforce

Surgical resources in South Africa: a review of the number of functional operating theatres

Background:Surgery has previously been neglected as a development initiative, despite the obvious effect of surgical illnesses on morbidity and mortality. Recently, greater attention has been given to surgical services, as there is growing evidence of cost-effectiveness of surgical interventions. Operating theatre numbers have been used as a measure of surgical capacity, despite there being limitations associated with this use of this metric. This study aims to analyse part of the surgical resources in South Africa. Methods: A descriptive analysis of surgical infrastructure in all nine provinces was performed. The total number of functional operating theatres was documented for all public and private hospitals in South Africa. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014.Results:The results showed 3.59 operating theatres per 100 000 population. This fell below the global average of 6.2 operating theatres per 100 000 as well as other developed countries. Theatres were concentrated in metropolitan areas, and there were a greater number of private operating theatres per insured population than in the uninsured public sector. Conclusion: Strengthening surgical systems will reduce the surgical burden of disease and improve health outcomes globally. Little is known about the available surgical resources such as operating theatre density, although using this metric to evaluate surgical capacity has its limitations

Geographical maldistribution of surgical resources in South Africa: A review of the number of hospitals, hospital beds and surgical beds.

BACKGROUND: The global burden of surgical disease has been studied to a limited extent. Despite the proven benefits of surgery, surgical services remain poorly resourced. Contributing to this global crisis is the critical lack of data regarding available resources. OBJECTIVE: To analyse the distribution of some resources necessary for the provision of surgical care. The distribution and number of surgical resources (number of surgical beds) relative to the general resources (number of hospitals and total number of beds) in South Africa were analysed. METHODS: All hospitals in the country, including those in the public and private sectors, were contacted, and the total number of hospitals, the level of care (district v. regional v. tertiary), the total number of hospital beds, and the number of surgical beds were determined. The data were analysed according to the provincial distribution and the public v. private sector distribution relative to the size of the population. RESULTS: A total of 544 hospitals were included in the study - 327 in the public sector and 217 in the private sector. The public sector hospitals included 257 district-, 49 regional- and 21 tertiary-level hospitals. Nationally, there were 1 hospital, 187 hospital beds and 42 surgical beds per 100 000 population. Gauteng Province (GP), the Eastern Cape, KwaZulu-Natal (KZN) and the Western Cape had the most hospitals and GP had the largest number of private hospitals. GP and KZN had the largest total number of beds (n=29 181 and n=22 889, respectively) and number of surgical beds (n=7 289 and n=4 651, respectively). GP had the largest number of private surgical beds (n=4 837). There was a marked variation in the number of hospitals, total number of beds, and number of surgical beds among provinces. CONCLUSION: This study provided an estimation of the number of hospitals, total number of beds, and number of surgical beds, and showed a marked variation among provinces and between the public and private sectors.

Incidence and management of postoperative bile leaks: A prospective cohort analysis of 467 liver resections.

BACKGROUND: Bile leaks from the parenchymal transection margin are a major cause of morbidity following major liver resections. The aim of this study was to benchmark the incidence and identify the risk factors for postoperative bile leakage after hepatic resection. PATIENTS AND METHODS: A prospective database of 467 consecutive liver resections performed by the University of Cape Town HPB surgical unit between January 1990 and January 2016 was analysed. The relationship of demographic, clinical and perioperative factors to the development of bile leakage was determined. Bile leak and postoperative complications severity were graded using the International Study Group of Liver Surgery and Accordion classifications. RESULTS: Overall morbidity was 24% (n = 112), with bile leaks occurring in 25 (5.4%) patients. Significantly more bile leaks occurred in patients who had major resections (≥ 3 segments) and longer total operative times (p < 0.05). There were 5 Grade A bile leaks which stopped spontaneously. Seventeen Grade B leaks required a combination of percutaneous drainage (n = 15), endoscopic biliary stenting (n = 8) and percutaneous transhepatic biliary drainage (n = 3). All 3 Grade C leaks required laparotomy for definitive drainage. Median hospital stay in the 442 patients without a bile leak was 8 days (IQR 1-98) compared with 12 days (IQR 6-30) for the 25 with bile leaks (p < 0.05) with no mortality. Major resections (≥ 3 segments) and total operative time (> 180mins) were significantly associated with bile leaks. CONCLUSION: The incidence of bile leakage was 5.4% and occurred after major liver resections with longer operative times and resulted in significantly extended hospitalisation. Most were effectively treated nonoperatively by percutaneous drainage of the collection and/or endoscopic or percutaneous biliary drainage without mortality.

A comparison of maprotiline (Ludiomil) and amitriptyline (1).

The study described here was designed to see if it was possible to show an earlier onset of action for maprotiline (Ludiomil) compared with amitriptyline while at the same time demonstrating equal long-term effectiveness and certainly no greater side-effects. A between-patient double-blind trial with 40 patients supported these aims and was statistically significant (p less than 0.001) with regard to early onset of antidepressant effect.